IUDs and IUDon’ts

14th July 2014

Rebecca Cooney

North American Editor for The Lancet

As part of the Affordable Care Act (ACA), the Department of Health and Human Services (HHS) requires that employer health plans offer coverage that provides full, recommended preventive care, including contraception services, with no cost sharing. But in the case of non-profit religious organizations and higher learning institutions that offer health-care plans but object to some contraception on the basis of religious beliefs, the HHS created an exemption process that allowed third-party administrators to provide contraceptive services. Almost a year ago, the HHS headily announced that this arrangement struck a balance between religious considerations and the basic coverage of essential preventive services for women’s health. Problem solved, right? Not quite. Enter Burwell v. Hobby Lobby.

Hobby Lobby, a nationwide chain of arts and crafts stores with about 21 000 employees and owned by an Evangelical Christian family, filed suit over the federal mandate for contraceptive coverage—not all contraceptive coverage, but four of the 20 forms of birth control protected under the ACA. The four contraceptive methods in question include two “morning after” or emergency contraception pills, copper intrauterine devices (IUDs), and progestin-releasing IUDs. Although Hobby Lobby has objected to these methods for being potential abortifacients, emergency contraception and IUDs are not classified as such by organizations including the American College of Obstetricians and Gynecologists. At the heart of the lawsuit, however, is the notion of whether a closely held for-profit corporation is allowed exemptions similar to those of non-profit organizations on the basis of sincere religious belief—regardless of whether a conviction is in line with medical consensus. In an unexpected turn, the US Supreme Court handed down a 5-4 ruling in favor of Hobby Lobby, suggesting that the HHS contraception provision violates the Religious Freedom Restoration Act.

The decision is fraught with possibilities and what ifs. The most frightening part of setting down this path is that there is no logical endpoint. For the few, selective exemption from provision of contraceptive coverage might be a victory of religious liberty. But for the many, it is a massive infringement on the requirement of basic comprehensive care and a glaring intrusion on the provider–patient relationship.

That being the case, why the relative quiet from the medical community? According to Shoma Datta, a gynecologist in New York City, for individual doctors and nurses “It’s an issue that often doesn’t get much coverage because it is something that a very small portion of medical providers in general deal with on a daily basis in terms of reproductive health and actually dealing with contraception or contraception services. So it’s a small percentage of health-care workers…It’s also a very politically charged and obviously very sensitive issue and it’s difficult to come out publically either with colleagues, in a work environment, or with patients.”

Minority of providers or not, the ruling should have all providers talking. The Hobby Lobby decision sets the stage for potential exemptions reaching into every domain of health care. Protecting the practitioner–patient relationship is protecting the practice of good medicine itself.

There are lots of reasons to have sex: connection, pleasure, or fun, to name a few. But feeling pain? That’s everything sex isn’t supposed to be. For many women, though, discomfort is a painful reality of getting intimate: As many as one in five young women say that intercourse consistently hurts. And the physical discomfort is only the start of their strife: Women with dyspareunia, the medical term for pain upon penetration, often fear losing their partner, feel sexually inadequate, and experience a dip in desire and satisfaction in the sack, according to the Journal of Sexual Medicine.
Yet many women say nothing—to their doctor, or to their partner. “There is a lot of depression and anxiety associated with this topic,” says Kenneth A. Levey, M.D., M.P.H., a gynecology professor and pelvic pain specialist at NYU.
But identifying the underlying cause of your pain is the first step to resolving it. To find out what may be making sex more painful than pleasurable, read on. (And to find a gynecologist who specializes in painful intercourse, visit the International Pelvic Pain Society website, where you can search for physicians in your area.)
1 of 8 Endometriosis
In a 2014 Journal of Sexual Medicine study, 75 percent of women with endometriosis (a condition where endometrial tissue grows outside the uterus) also suffered from sexual pain—often leading them to avoid sex. Deep penetration can put pressure on areas where endometriosis occurs, such as the ligaments attaching your uterus to your pelvis or the lining of your pelvis. “Anything that touches those areas—a penis, a tampon—can be extremely painful,” says Levey.
2 of 8 Overactive Pelvic Floor Muscles

Your pelvic floor (a group of sling-like muscles that support your uterus) is supposed to relax during sex. But in some women, these muscles constrict, often as a result of difficult childbirth, sitting too much of the day, or past sexual abuse, according to Virginia Tech researchers. “Pelvic floor muscle spasm is far and away the number one most under-recognized cause of painful intercourse,” Levey says. “Not a lot of doctors are looking for this cause—sometimes they just tell a woman she has a tight vagina, which is ridiculous.” Signs to look for: a burning, throbbing sensation at the entrance of your vagina, which can last for hours or days after sex.
3 of 8 A History of Urinary Tract Infections

If your medicine cabinet is regularly stocked with antibiotics, you may be predisposed to penetration pain. In a 2013 study, Italian researchers found that women with “provoked vestibulodynia”—a type of discomfort triggered by pressure around the vaginal opening—had a higher number of UTI’s than pain-free ladies. [Tweet this fact!] “Infection leads to nerve hypersensitivity,” says Levey. “Normally, nerves calm down over time. But if you get another infection within a couple weeks or months, those nerves never have time to relax.” That means the entrance to your vagina is incredibly sensitive, so much so that even attempting penetration can be intolerable. (Excessive use of antibiotics may lead to recurrent infections too, triggering severe inflammation and a greater risk of pain around your vulva, the study authors say).
4 of 8 You’re Not Lubing Up

If you’re not sufficiently wet, your partner’s penis may feel far from pleasurable. An estrogen drop (a common side effect of menopause, childbirth, or breastfeeding) could be to blame for a lack of lubrication, according to Mayo Clinic experts, or you just may not be aroused enough. In this case, the fix is simple: silicone-based lubricants, says Levey, which tend to be slicker than water-based varieties.
5 of 8 Fibroids
Fibroids (a type of rubbery growth in your uterus) may set your sex life on fire—and not in a good way. “Pain with fibroids tends to be a quick, fast, sharp pain,” says Levey. In a recent Journal of Sexual Medicine study, women with fibroids were three times more likely to report severe pain during sex than those without the growths. “Fibroids can indent into the vagina, and the act of hitting them can be incredibly uncomfortable,” Levey explains. Another cause of discomfort: As fibroids increase in size, they may die off, leaving your uterus inflamed and primed for pain, he says.
6 of 8 A Tilted Uterus

Women with a tilted uterus have a higher risk of endometriosis (a common cause of sexual pain), says Levey. An off-kilter uterus may also be directly linked to discomfort: “When the top of the uterus is tilted back, the penis can hit that,” Levey explains. That can lead the supporting tissues to stretch, ultimately causing pressure and pain. Other signs of a tilted uterus: menstrual pain, back pain during sex, UTI’s, and trouble using tampons, according to the American Pregnancy Association.
7 of 8 A New Baby

Nearly half of nursing women reported pain six months after childbirth, compared to 30 percent of new moms who weren’t breastfeeding, a 2014 study in the International Urogynecology Journal found. Vaginal delivery can also cause tearing and nerve damage (ouch!) and breastfeeding may temporarily affect your body’s ability to lube up during sex, says Levey.
8 of 8 Stress!

Anxiety alone probably won’t make sex a pain—but it can set you up for a number of conditions that trigger tension below the belt. “Stress often causes changes in the pH of the vagina, which can lead to bacterial infections,” says Levey. A bad case of the nerves may also cause pelvic floor muscle spasms, while reducing your overall tolerance for pain, too, he says.

Dr. Kenneth Levey is the leading expert on the use of indocyanine-green for detecting endometriosis. He has published a recent report on his initial findings. Another report is planned soon in which he will report on positive predictive value, negative predictive value, sensitivity and specificity. We are very excited about this breakthrough in our ability to detect the extent of endometriosis lesions.

NY Pelvic Pain and Minimally Invasive Gynecologic Surgery, P.C. announced Dr. Kenneth A. Levey has been recognized among the leading doctors in the region by Castle Connolly in their 17th edition of “Top Doctors: New York Metro Area.” Each year “Top Doctors: New York Metro Area” identifies the top 10 percent of primary care and specialty doctors in the metropolitan New York region.

Dr. Levey is a top minimally invasive gynecologic surgeon and specialist in endometriosis, chronic pelvic pain and uterine fibroids. He has been identified as a leader in daVinci robotic surgery and single site invisible incision surgery. Dr. Levey is an assistant clinical professor at the NYU Langone Medical Center. Dr. Levey serves as a proctor and educator to other gynecologists seeking to advance their skills in minimally invasive surgery and advanced endometriosis surgery. Surgeons travel from around the United States to come see him operate and learn from him at the NYU Langone Medical Center.

Dr. Levey is the first benign gynecologist in NYC to perform single incision robotic surgery.

In the past I have been required to perform complicated robotic surgery procedure through 4-5 incisions. Although the incisions are quite small (usually 8mm) they still produce a cosmetic defect. Now I am able to perform these procedures through a single incision. The incision is placed in the umbilicus (belly button) and once the surgery is completed the incision is essentially invisible. Rarely, it is necessary to add a second incision. If this does occur then there will be only one 8mm incision that is visible.

With my surgical colleague, Dr. Mark Reiner, I have been able to perform single incision robotic surgery on women who otherwise would have required a large abdominal incision or multiple small incisions.

We have performed all of these procedures on an outpatient basis – so you can go home on the same day. We have done them and will continue to perform such procedures in a free standing ambulatory surgery center. Midtown Surgery Center is an international leader in outpatient robotic surgery. Midtown Surgery Center offer our patients a higher level of comfort, service, and individualized attention.

If you have a condition that requires surgery we recommend a consultation with Dr. Levey or Dr. Reiner so we can maximize your opportunity for a minimally invasive procedure with the optimal cosmetic outcome, comfort, safety, and individualized care.

On November 11th Dr. Datta was an invited speaker at the launch event for Endo
Warriors, a support organization for women with endometriosis. The group aims to
provide a network for support meetings and resources for medical treatment. The
well attended launch night included discussions of personal experiences as
endometriosis patients of all 3 founders and the process which lead them to
establish this group. Dr. Datta spoke on the multimodal and
multidisciplinary approach to treatment of endometriosis and chronic pelvic
pain. This approach to endometriosis includes addressing its effect on pain,
fertility, urinary, gastrointestinal and psychological symptoms.

Our practice provides expert care in the medical and surgical treatment as well as a
team approach with our medical colleagues for the comprehensive care so crucial
to endometriosis treatment.

On August 27, 2013 Dr. Levey presented a webinar on on endometriosis resection in women with chronic pelvic pain. He highlighted the use of indocyanine green. Dr. Levey is the first to have used this advance technology for diagnosing endometriosis intraoperatively. The webinar can be found on you tube by clicking here.

Our director, Dr. Kenneth Levey will speak and present techniques is robotic surgery and endometriosis removal to an international audience at UCLA’s David Geffen School of Medicine. He will be presenting techiques in robotic hysterectomy as well as proper patient selection. He will also be presenting groungbreaking techiques in endometriosis resection using the daVinci robotic surgery platform. Click here for a link to the course brochure.

Our new location will offer women the convenience of a great location and the straightforward hassle free service required fit your women’s health visit into your busy day. Patient will continue to be able to access our award winning patient portal in order to communicate with their physician, request prescriptions and schedule appointments.

Pur phone number is the same 646 290 9560 and you can still make appointments through our portal or via ZocDoc.